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Title of the Document Happens Here The #StaffCare Guide: How to Support & Protect Health Care Workers ihi.org October 2021 ihi.org 1 Title of the Document Happens Here Authors Gareth Kantor, Faculty, Institute for Healthcare Improvement. Assistant professor, Case Western Reserve University, Cleveland, OH. Honorary lecturer, University of Cape Town, Department of Anaesthesiology and Perioperative Medicine. Beth Engelbrecht, Faculty, Institute for Healthcare Improvement. Adjunct Associate Professor, University of Cape Town, School of Public Health Nelson Kamoga, Faculty, Institute for Healthcare Improvement Pierre Barker, Chief Scientific Officer, Institute for Healthcare Improvement Maureen Tshabalala, Senior Director, Institute for Healthcare Improvement Aleya Martin, Senior Project Manager, Institute for Healthcare Improvement Patience Manyau, Associate Project Manager, Institute for Healthcare Improvement Acknowledgments We wish to acknowledge health care leaders and staff all across South Africa for their commitment and care, especially those who came to the front, when it was most needed. They shared with us and their colleagues their leadership insights and practical ideas on how to deliver care and take of each other, and how to do so, in the most challenging circumstances of our professional lifetime. We also acknowledge the partners in provinces as well as university and private expert volunteers. Institute for Healthcare Improvement For 30 years, the Institute for Healthcare Improvement (IHI) has used improvement science to advance and sustain better outcomes in health and health systems across the world. We bring awareness of safety and quality to millions, accelerate learning and the systematic improvement of care, develop solutions to previously intractable challenges, and mobilize health systems, communities, regions, and nations to reduce harm and deaths. We work in collaboration with the growing IHI community to spark bold, inventive ways to improve the health of individuals and populations. We generate optimism, harvest fresh ideas, and support anyone, anywhere who wants to profoundly change health and health care for the better. Learn more at ihi.org. © 2021 Institute for Healthcare Improvement. All rights reserved. Individuals may photocopy these materials for educational, not-for-profit uses, provided that the contents are not altered in any way and that proper attribution is given to IHI as the source of the content. These materials may not be reproduced for commercial, for-profit use in any form or by any means, or republished under any circumstances, without the written permission of the Institute for Healthcare Improvement. eport ihi.org ihi.org 2 Title of the Document Happens Here Contents I. Background and Key Concepts 5 A. The coronavirus pandemic, the stressed health care workforce, current and future possibilities 5 B. #Staffcare’s purpose and main ideas 5 C. About this Guide 7 1. What problem can this Guide help to solve 7 2. What happened in #StaffCare? 7 3. The learning system with external partners 11 4. Taking action in an authorising context (the WHAT and the HOW) 13 5. Culture change – how to begin 15 6. The leadership and culture journey of the WC Department of Health 15 II. The #StaffCare Action Bundle 17 A. Effective leadership and Management 17 1. Undertake regular #StaffCare Leadership Rounds 18 2. Communicating Effectively and Often using Multiple Channels 21 3. Conduct Regular Team Huddles 22 4. Conduct Meaningful Business Meetings 27 5. Establish Trusting Relationships with Organised Labour 28 B. Prevent and Manage Harm to HCWs 30 6. Prevent infection and other forms of harm 30 7. Take care of colleagues who become infected or experience other workplace harm or injury 32 8. Ensure staff are knowledgeable and prepared 35 C. Preserve mental and physical health of HCWs 36 ihi.org 3 Title of the Document Happens Here 9. Support the Emotional well-being of staff 36 10. Care of basic needs and an enabling work environment 41 III. Engagement and Partnership Development 41 IV. The Organisational Form of #StaffCare 43 A. SteerCom 43 B. CoLab 43 1. Planning a CoLab 43 C. Focus Group 45 D. Mentoring 48 1. How to offer and what to offer 48 2. Factors affecting attendance 48 V. Digital tools that enable #Staffcare 49 A. #StaffCare’s digital platform for engagement 49 B. #StaffCare’s website 49 C. Social media, WhatsApp and other messaging technologies 51 D. Interactive real time polling 53 E. Other technologies 53 1. Digital storytelling 53 2. Chatbots 54 3. Mobile Apps 54 4. Internet-based support groups 55 5. Vula Mobile 55 VI. Using Data for Learning and Improvement 56 VII. References, Resources and Tools 58 ihi.org 4 Title of the Document Happens Here I. Background and Key Concepts A. The coronavirus pandemic, the stressed health care workforce, current and future possibilities During the global coronavirus pandemic, health care organisations have had to deal with unprecedented disruption and a rapid pace of change. High levels of burnout existed before the pandemic but staff have now endured a type and degree of severe, sustained workplace pressure not seen before. There are positives however. Amidst this pressure, many leaders learned quickly, communicated effectively, and found ways to support staff experiencing anxiety, stress and intense demands. They allowed staff themselves to identify their main issues and concerns, and to develop solutions. Sometimes this meant bypassing long established but unhelpful or unnecessary rules or customs. The successes of these organisations and leaders coping with the pandemic suggest that there are opportunities to build more robust systems for the long term that will enhance satisfaction with work now and in the future. Stable, responsive and capable leadership is required to navigate the challenges and make change in established, complex systems. #StaffCare emerged from the desire to support leaders and managers to learn and to take on these tasks. Through better care of leaders, and staff, patients are likely to benefit also. B. #Staffcare’s purpose and main ideas The purpose of #StaffCare was to strengthen the capability of the health care system’s leaders and managers to actively support and protect those who work in it. #StaffCare co-created a Sense-making Framework (SF) of key workstreams and associated action ideas that would help leaders and managers to achieve a healthier and more supported workforce. The Framework included what were conceived of as measurable aims (fewer staff infected with Covid-19, lower absenteeism and better emotional health) driven by three key action streams: (1) effective leadership and management, (2) prevention and management of harm to health care workers, and (3) preservation of mental and physical health of health care workers. Figure 1: Sense-making Framework ihi.org 5 Title of the Document Happens Here #StaffCare became part of a learning health system operated entirely in a digital (virtual) environment. It was implemented via two groups of health system leaders: the catalytic innovation community (the Focus Group of mid-level leaders) and the large-scale spread community (CoLab). The #StaffCare guidance group (SteerCom) pursued connections to various sectors, departments, and stakeholder groups in the health system in order to deepen organisation-wide learning by connecting to a broad range of frontline experiences, ideas, and innovations. #Staffcare pursued collaborative partnership arrangements, for example between the “technical” support partner (IHI) and the implementing health system; between frontline staff and supervisors; between participants who face similar challenges in the system; between external organisations; interprovincially; and between universities Principles and values that were considered important contributors to #StaffCare’s intended outcomes included the following: 1. Respectful engagement with leadership 2. Aligning with Health Department priorities 3. Developing relational perspectives 4. Recognising the health system to be a complex adaptive system 5. Using collaboration and co-creation 6. Fostering an authorising environment and an enabling culture ihi.org 6 Title of the Document Happens Here Figure 2: The Learning Network #StaffCare provided a venue for regular sharing of provincial data on health care worker (HCW) COVID-19 infections and mortality trends which raised awareness and generated discussions and ideas on how to prevent and manage potentially fatal disease transmission, including best practices for stopping staff-to-staff and patient-to-staff infections. By the time of the funder- supported part of the initiative in October 2020 concerns about staff contracting the virus at work had diminished significantly. From then, the focus shifted more to promotion of staff well- being via leadership action, an important long term priority, with #StaffCare providing a mechanism for learning and improvement. C. About this Guide 1. What problem can this Guide help to solve Health care systems in South Africa and globally face the problem of burned out and demoralised staff whose emotional wellbeing is threatened, and whose capability at work is reduced due to the challenging nature and circumstances of their work. This Guide is an extraction of lessons and experience gained during the #StaffCare initiative offered to leaders and others who wish to address this critical problem. This Guide may therefore be helpful to other local health care organisations who wish to begin a similar journey and set up or strengthen similar mechanisms, platforms and processes for learning and improvement. 2. What happened in #StaffCare? During #StaffCare, health system leaders and managers experienced new ways of learning – on a virtual platform - about the system’s role in the creation of and response to this burnout. They thought about better short and long-term options for preventing it, and for creating workplace systems and conditions in which all health care workers could thrive. This learning focused on system thinking, leadership, systemic workplace factors and key actions that play a dominant role in staff wellbeing. Participants were able to safely share their ihi.org 7 Title of the Document Happens Here experiences, insights and ideas about leadership and the actions they were or could take to support and protect their staff. The Guide describes the organisational “form” that guides and uses the virtual platform: a steering group (Steercom), a small, diverse core (Focus Group) of frequent participants, and a wider community (the CoLab). The Focus Group is intended to be representative of the mix of services and settings in the health care system and to generate energy, learning, creativity and a positive mindset. Prioritised themes emerge, are mapped to the framework, taking context into account, and are targeted for further learning and, ultimately improvement action. The Focus Group’s ideas and experiences are brought to the wider community (the CoLab), the overall programme and initiative being guided by the Steercom. #StaffCare offers an appealing and interesting format of regular engagement to which participants repeatedly return. Some organisations may wish to create their own platform or join others that already exist. Whilst each workforce care unit has a unique set of objectives, skills, and activities, collectively they have a common goal which is to have emotionally healthy HCWs who show up for work, and effectively render a service in well-functioning teams. Many of #StaffCare’s activities were therefore about deepening the understanding of the systems that all leaders are part of and to encourage discovery and sharing of a set of key behaviours and actions available to them. The Guide highlights six important themes: the importance of hearing the concerns of the workforce directly from them, of preparing staff for the daily challenges they face, caring for their emotional wellbeing, protecting their physical and mental health, offering support through health and other challenges, and honouring staff for their contributions. #StaffCare has tried to further strengthen the enabling and endearing culture (see Culture Shift – page 7) in which leaders, managers and their teams could feel safe to surface problems. #StaffCare found that showcasing what people were able to do encourages others even in the absence of formal systemic improvement initiatives. #Staffcare offered individual mentoring to promote participants’ growth in their ability to navigate their system and use quality improvement methods and resources. #StaffCare encouraged measurement, for example of absenteeism rates, and levels of emotional wellbeing, to gain deeper insights into how their staff are doing and to guide action. We will give examples, stressing that measurement can be simple, directed and effective but cannot by itself change the system. #StaffCare was a partnership between health departments and external partners, primarily IHI. The Guide may therefore assist in understanding how to identify and work effectively with partners who can support the organisational goal of health system strengthening for staff well- being, arrangements that if successful can strengthen other aspects of the health care system too. A health system’s internal resources – primarily the highly limited time and attention of leaders and managers - are required to initiate and sustain the work of #StaffCare but this is felt be a worthwhile investment in the most important resource of the health care system – its staff. ihi.org 8 Title of the Document Happens Here a) Who is this Guide for? #StaffCare’s activities were focused on mid-level clinicians and managers holding responsibility for connecting the frontline to the centre, and for frontline HCWs and teams across provincial health care systems. #Staffcare also sought to engage upper-level health system leadership responsible for the health care workforce as a whole. For initiatives like #StaffCare to succeed requires prioritisation by senior leaders. They can highlight its value through participating in it themselves and by supporting the release of resources required to respond to system and staff care needs. This Guide, therefore, is primarily for mid and upper-level health system managers in all kinds of workforce care units but may also be useful to sponsors and partner organisations. b) Where should #StaffCare be located in an organisation? #StaffCare has had an audience (mid- and upper-level managers), content (ideas for improvement from the staff themselves) and method (learning and action network) that differentiates it from the role and activities of HR or Occupational Health Services (OHS). #StaffCare should therefore be considered not primarily an HR or OHS undertaking, but a strategic lever for health system strengthening and organisational performance. Given its direct link to the efforts to promote an enabling environment for change and its connection to managers and leaders, initiatives like #StaffCare could be sited in the office of the CEO, strategy or system improvement section, or equivalent. At this organisational level, coordination with external partners may be more effective, the high priority of staff wellbeing is signalled, and responsibility for the crucial mid-level cadre of leaders and managers, whether clinicians and non-clinicians may best be held.Locating #Staffcare is also about mandating, authorising and establishing accountability and reciprocal responsiveness. c) Key areas of action During the #StaffCare initiative a theory of key ideas and key areas of action emerged from assessment of the essential needs for wellbeing during the Covid-19 pandemic. The three key action streams were: 1. Effective leadership and management 2. System level action streams that prevent or manage harm 3. System level action streams that preserve or enhance physical and mental health Of these three areas of action, emergent system needs put most attention to stream #1, which includes visible and decisive management, effective communication, and relations with Organised Labour. The enablers for these and other actions which could be taken by mid-level leaders are an endearing and enabling culture and an authorising context, described further below. ihi.org 9 Title of the Document Happens Here d) Matching #StaffCare to your context The organisational context for #StaffCare is very important. The #StaffCare initiative emerged in a large province (WC) that was already significantly invested in a multi-year leadership culture journey. The desired leadership competencies were identified and systematically implemented. A practice of distributed leadership, with the required authority and accountability, was established to ensure decision-making as close as necessary to the frontline. A leadership behaviors charter was co-created through consultation with staff cadres across the system. Leadership values and behaviors became prominent requirements and features of leaders. Trusting relationships and safe reflective spaces have been features of the WC health care system. These prior efforts created receptive conditions for a virtual learning and action network. While all settings have needs for staff care and protection, their needs may be different. Contextual differences must be recognized and understood by leaders. The variety of contexts can generate different and useful new ideas and insights. If the health system spans many different contexts, the learning system also needs mechanisms to connect different components and different contexts. For example, provinces and other organisations differ widely in terms of prior investment in leadership and culture change and the stability of senior leadership. Since any new initiative requires leadership endorsement and support (an authorising context), leadership instability or absence will be a major determinant in establishing #StaffCare. In some provinces the head of department position has been vacant and other key positions have turned over rapidly. Frequent political leadership changes can have important and potentially destabilising effects. Leaders working in less stable or resourced settings may still find #StaffCare’s example, and this Guide, to be useful by applying it in a more localised setting. Districts, sub-districts and large hospitals may have relative autonomy to create ecosystems like #StaffCare that could provide an enabling, values-driven environment to strengthen positive behaviours and trusting relationships – a place where staff feel safe to speak up and try things out. Organised Labour will feel welcomed in these spaces. Smaller components of the health system may in fact have conditions for better connectedness and teamwork. Larger entities, such as metropolitan districts and sub-structures, are more complex, include many more relationships, and are subject to power influences. The culture in rural settings on the other hand may reflect a “can-do” (resourceful) approach due to strong, trusted networks used to working with limited resources. Urban settings can reflect the challenges of larger organisational components with weaker, less trusting networks. During the Covid pandemic, tertiary institutions have experienced a large care burden pressure in acute medicine and intensive specialties, whilst surgical services had to scale down and often moved into giving care in COVID wards. However, urban areas do enjoy the benefit of research/academic institutions and their technical resources (e.g. expertise, data, training). Primary care staff during COVID carried a significant burden in terms of disease and case containment strategies, first contact care and vaccination burden. The pressure and staff ihi.org 10 Title of the Document Happens Here configuration in primary care settings may be particularly susceptible to limited availability of managerial and clinician leaders. Such realities demand creative mechanisms for these teams to actively participate in #StaffCare activities. e) Framing #StaffCare as a response to “requests from Health Care Workers” The April 2020 study by Shanafelt et al described sources of anxiety during the Covid-19 pandemic and characterized the main “requests from health care professionals to their organisation”. (https://jamanetwork.com/journals/jama/fullarticle/2764380) These five requests, or themes: “hear me”, “protect me”, “prepare me”, “support me”, and “care for me”, helped define how #Staffcare was understood, developed and organised. A sixth theme, “honour me”, almost an afterthought in the article, was very important in our context. As the unparalleled stress of rapid change during the pandemic recedes, the relevance of these 6 themes still remains. Figure 3: The Shanafelt Themes are requests by health care workers during the Covid pandemic 3. The learning system with external partners During the most difficult periods of the Covid-19 pandemic, leaders could not eliminate stress and anxiety but could try to create conditions that allowed staff to be at their best in difficult circumstances. #StaffCare was an attempt to create such conditions in a learning system where participants could share information, ask and discover “what matters” to them and other staff, solicit input and ideas for problem solving, discover what works or does not, while acknowledging uncertainty and vulnerability. #StaffCare provided opportunities for helpful leadership activities to be described, displayed, modeled, and become part of the “new normal”. It helped to create a trusting and enabling environment and culture for health systems to adapt to shocks and stresses. The safe spaces and/or psychological safety that are needed are the outcomes of a myriad of different behaviours, practices, and hard work over time. They are not created in or by one workshop, project, practice, or tool, or by measuring it, though measurement can help determine whether and to what extent the right conditions are present. Figure 4: #StaffCare Partnership – Strengthening the health system for staff and public benefit ihi.org 11 Title of the Document Happens Here Figure 4 is a conceptual diagram that captures some of the main features of #StaffCare, including its purpose (the “WHY”) - to address health worker distress and burnouts. It also seeks to illustrate certain key links and feedback loops of learning within the health system 1. The figure highlights the links between staff wellbeing and public benefits i.e. patient/population health outcomes. In a nutshell, staff who “feel better” can “work better” 2. #StaffCare’s key drivers/actions and action stream as contained in the sensemaking framework are the “WHAT”. Existing internal services (People Management, HR; Occupational Health Services, line management) should link to the learning and action network, applying collaborative single, double and triple loop learning (see below) across the system and components “The aims and results of learning depend on the type of learning ‘loop’: single, double or triple. Single-loop learning can support changes in regular actions by adapting normal routines and practices, but tends to overlook the assumptions on which these are based. Double-loop learning goes further to question and influence frameworks, models and assumptions around problems and their solutions, and can drive deeper shifts in objectives and policies. Triple-loop learning, often referred to as “learning how to learn”, challenges fundamental assumptions and improves the way in which the system learns.” Learning health systems: pathways to progress. Alliance for Health Policy and Systems Research. World Health Organisation. 2021. Page XIV ihi.org 12 Title of the Document Happens Here 3. A partnering approach across actors and teams within the system, as well as with external partners who align with organisational aims, assist with sensemaking, provide supportive tools, and a learning system design. (The “HOW”) 4. Taking action in an authorising context (the WHAT and the HOW) Leaders and managers need an authorising context in which they are enabled to try out the key actions presented in Section II. An authorizing context is one in which these leaders (clinicians and managers) are permitted, or encouraged, to take decisions to respond to local challenges, or to improve local situations. Authorising happens in various ways, for example formally through official communication and delegations of responsibility, or by using a distributed leadership approach where leaders are given autonomy for decision-making, using safe, reflective spaces to generate learnings. The authorising context requires a blame-free approach; when things go wrong, leaders need to be supported, use these opportunities for learning, and be provided with resources to implement local solutions. A recommended approach for taking action to support health care workers is to begin by soliciting ideas from frontline staff and their leaders. Administer the Emotional Pulse Check Survey (See Figure 5) using responses from questions #8 (“describe three things that matter most to you in your work life”) and #9 (“share one or more suggestions about how your organisation could make you feel more heard, protected, prepared, supported and cared for”) to collect possible actions and to attach them to the relevant action streams and actions in the SF. Figure 5: George Hospital, WC, used the emotional pulse check survey to assess its workforce during the first Covid-19 pandemic, July-August, 2021 ihi.org 13 Title of the Document Happens Here These actions depend on the organisation’s readiness to accommodate and support change, at unit level or higher up and across the system. There is always limited capacity to do so; no organisation can take up all the feasible actions at the same time; prioritisation is required. Example of possible changes (actions) are described in Section II. It is important to ask staff “what matters ” most in their work life – what are the key challenges they are facing and and their ideas for change. Senior leaders should always acknowledge these inputs and should communicate how and when they will be used, or the reasons for not doing so at the present time. The need that the changes addresses is publicly recognised and communicated. Failure to act on ideas elicited from frontline staff and leaders/managers may cause disappointment. ihi.org 14 Title of the Document Happens Here Clinical managers may experience the most frustration with lack of translation of their good ideas into action; or not having access to resources to leverage change; sharing insights and explanations regarding the resource limitations and balancing of priorities that managers face may help. QI (quality Improvement) mentoring has been a further element of #StaffCare. See under Mentoring in Section IV. To connect leaders to online resources for “just in time” learning consider consulting with your Quality Improvement department or staff. The following free resources are available from IHI: • Quality Improvement Essentials Toolkit • Seven Popular Improvement Tools: How (and When) to Use Them 5. Culture change – how to begin Based on experience in the W Cape, the following steps can be taken to build a culture receptive to #StaffCare: Consult with frontline staff and their leaders about the parts or processes in the system that work for them – or do not. Ask how they wish the system to work better for them. Add to this any relevant staff survey results (such as those measuring entropy levels1), the presence of pockets of toxic leadership practices, staff unhappiness, grievances, etc. Also enquire about disablers of local decision-making. Package the resulting “diagnosis” and findings and commence a journey of defining the values people wish to see and the behaviours linked to it. Senior leadership needs to visibly lead this process. Once a leadership pledge of service and behaviours are crafted, communicate this and make it visible. Confirm it at every session where staff convene. Have performance conversations include discussions about values and behaviours. Visibly delegate decision-making and have leaders visible in the frontline through various visits. An important principle is that every person in the organisation who has influence over any other person is regarded as a leader and has to live by the values and behaviours contained in the pledge. 6. The leadership and culture journey of the WC Department of Health 1 Entropy is the mismatch between staff attitudes and expectations and the reality of their workplace. Cultural entropy speaks to the level of mismatch between personal values and the experience of organisation values. It is a negative feature and a measure of an environment of disablement. Surveys can measure the number of aligned or misaligned values. ihi.org 15 Title of the Document Happens Here A leadership culture change journey assisted the W Cape Health Department to move from an unsafe working environment towards an “endearing culture” where staff feel inspired and are driven toward innovation and creativity.. The Department invested in leadership development, established a leadership behaviours charter, and intentionally connected the frontline to the centre through consultation and co-creation. The approach to culture change used the Cebano model (see Figure 6 below). Leadership styles were systematically shifted to the right, to abandon toxic styles (abusive, punitive, fear driven), reduce rigidity (rules-based, compliant, inflexible), and move to good (efficient, productive, short-term profit,) great (team collaboration, innovative, emotional awareness) and endearing (stakeholder collaboration, shared values, context awareness, greater good, decentralised team-based decisions, ease despite uncertainty) types of organisational culture. Leadership values assessments every second year showed the shift in entropy levels, which measure the level of alignment between the desired culture of staff to what they experience at the workplace. The findings pointed to areas in the system where leadership interventions would be required. Intentional interventions to raise the quality of leadership, cohesiveness and connectedness across the system all contributed to improvement. Figure 6: Cebano Model . ihi.org 16 Title of the Document Happens Here II. The #StaffCare Action Bundle The #StaffCare Crisis Action Bundle was created in December 2020 during the second Covid-19 pandemic wave, a time of severe pressure on the health care system. The Crisis Action Bundle continued to evolve during 2021 and, now termed simply the Action Bundle, describes 10 key actions. These are suggested priority activities that could be undertaken by other organisations. They reflect experience, knowledge and ideas acquired from presentations and discussions during various #StaffCare engagements. A bundle is a small number (3-5) of elements that have supportive evidence and are implemented concurrently. Outcomes may then surpass what is possible with individual elements i.e. the sum of the whole is greater than its parts. Evidence supports many of these interventions individually, and the concept of a bundle is borrowed mainly to highlight that several actions may be needed and single solutions do not exist. Introducing 10 action bundle elements simultaneously however is difficult or impossible and not recommended. Figure 7: #StaffCare Action Bundle lists 10 key actions, described in detail below, clustered in 3 action streams. A. Effective leadership and Management Main messages: Response to the pandemic required quick action and improvisation. Effective leadership was described as being visible and decisive. Visibility was created through conducting regular in person (preferably) or virtual engagements with staff, such as huddles and Leadership Rounds. Despite uncertainty, leaders needed to be decisive in their actions. This seemed more likely to occur when leaders enjoyed strong connections with other leaders across the system with whom they could share lessons and insights. ihi.org 17 Title of the Document Happens Here In the requirement for quick action, the crisis uncovered the potential for reduction in exaggerated compliance, audits, and tick-box culture. Acountability could instead be based on true value add, personal and team growth, making a difference, and bringing improvement. Communication was critical. The sharing of information by leadership with staff created confidence even when conditions were acknowledged to be difficult and fostered the ability to quickly make decisions and act on them. Effective communication also sometimes involved the sharing of experiences and of feelings that accompanied them. In these communications leaders allowed their vulnerability to show, which then allowed staff to connect with their own feelings, knowing they were not alone in these experiences. Health systems that developed distributed leadership, and an approach that emphasised learning rather than blaming, seem to have been more successful. Distributed leadership is not “centred at the centre” but placed all across the organisation, and is not necessarily linked to a title, but rather to a behaviour and/or a role in the system. 1. Undertake regular #StaffCare Leadership Rounds Contributors: Donna Stokes, Anthony Reed, New Somerset Hospital Context: During the pandemic leaders often found the best way to immediately establish how staff were doing was not to summon them to an office but to “go see”. Some hospitals indicated their willingness to turn this into a regular leadership practice. Use of #StaffCare leadership rounds can be considered and shaped in ways relevant to each setting. Aims: To conduct frequent visits to the frontline (the setting of work) to listen to and communicate directly with clinical and support staff, in order to gain deeper insight into how, where and by whom work is actually done, and develop useful systemic and unit levelresponses. Description: Leadership rounds may be conducted by various leaders in the chain of care. These may be senior leaders, for example the Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Medical Officer (CMO), Operational Manager nursing (OM), with or without support staff. In district settings, the District manager, Sub-district managers may do Leadership Rounds with or without Critical support staff. Senior leaders at provincial level, such as the Chief of Operations or the HOD, with critical support staff, such as infrastructure and People Management, may wish to have a scheduled visit program to subdistricts, or health system components such as emergency medical services, mental health delivery, primary care, or a large hospital. Several members of the senior executive team can participate to allow multiple perspectives for rapid problem solving. Leadership rounds can be done during scheduled time set aside on a regular basis. The frequency of rounds may differ, e.g. daily, weekly – or done ad hoc. ihi.org 18 Title of the Document Happens Here Rounds may be conducted in patient care areas e.g. clinics, wards, theatre, in pharmacies and laboratories, and in administrative support service units. In fact, any and all parts of the health care facility. The time for these rounds ideally is protected. Virtual sessions can be considered instead of postponement or cancellation. A conversation between the leader(s) and one or more employees can begin and develop in various ways. Table 1 below has suggestions that may help staff to surface what matters to them and their ideas for change. The act of doing leadership rounds is to make it safe to speak about concerns and issues by active listening, maintaining privacy (if required) and avoiding judgement. Focus on the issues that teams and team members bring. Conclude each round with a reflection on what has been learned about the system and any response that will follow. Record and act on any “just do it” quick fixes so that front-line staff see action follows engagement. The aim of Leadership Rounds is not to generate grocery lists of actions, or to make promises but to reflect on what we learn about the system and how to responds to needs. When you identify gaps, focus on the system, not individuals. Table 1: Suggested conversations with staff at #StaffCare Leadership Rounds Suggested introductions Ideas for questions that open the conversation “What makes for a good day at work?” “We’re moving as a hospital to more open “What matters to you?” communication. We want to make this a “How can we make this workplace safer and place in which all our staff feel safe, are healthier for you and your team-mates?” consulted often, and feel free to express “What in the workplace hampers your wellbeing?” their needs and problems that they see in “What ideas do you have to improve your reality?” the workplace. We want people to be able “What would you do if you were in my position?” to express their concerns about the work “Can you think of events or circumstances at work environment and how it affects their safety in the past day or few days that have made you feel and wellbeing.” anxious or upset?” “Have there been times recently where you felt your “The discussions we’d like to have are physical or mental wellbeing were at risk?” purely to support and protect health care “Have there been any incidents lately that you can workers across the hospital. What we talk think of where a colleague was harmed at work? about won’t go beyond this small group if “What aspects of the work environment are likely to you don’t want it to.” harm you or cause dissatisfaction?” “Is there anything we could do to improve your “We are committed to finding the ‘pebbles physical environment at work?” “Is there anything in the shoes’ of our staff. We will try to we could stop doing?” remove these while we make plans to ihi.org 19 Title of the Document Happens Here address bigger and more difficult “What actions from leadership would make work problems.” safer and more enjoyable for you?” “What would make these Rounds more effective?” A way to close the conversation “Do you find this to be a place where open “We’re going to work on the information communication is encouraged?” you’ve given us. In return, we would like you to tell two other people you work with about the concepts we’ve discussed in this conversation.” “since I started being a manager (21 yrs ago) it just was instinctive and natural to spend significant time in hospital.. walking about, seeing pressures, problem solving e.g. finding beds and chatting ‘on the fly’ with staff.. any category. Sometimes it was directed to work, other times just a light-hearted chat to cheer folk up.” “I wouldn’t want to go in with too many questions and maybe just one that we chose for that ward and then another for next ward as then staff can feel free to engage with that point as time is limited and we don’t want them to feel like… 20 questions in 20 mins!!! So a themed meeting?” -Donna Stokes, CEO New Somerset Hospital During Covid, doing leadership rounds away from clinical units may be a necessity. “with Covid waves we can also do it away from direct workspace surely. In summer one can go sit outside (the new shelter is a perfect venue).. with a set time and a few staff so the ward doesn’t suffer too much. They would be out of patient care anyway if we met near the ward or in it…staff may feel more relaxed to chat also.” “I worry about the inevitable resource questions as there are just none!.... But things we can solve are lying unaddressed as we probably don’t know about them…. the softer issues such as just visible caring can really help”. -Donna Stokes, CEO New Somerset Hospital Figure 7: The Rotary Staff Rest Area at New Somerset Hospital was funded and built by a local Rotary club. It is an example of a community project to support health care workers. The idea for this safe outdoor dining and rest area came from a hospital leader hearing the needs of staff. ihi.org 20 Title of the Document Happens Here 2. Communicating Effectively and Often using Multiple Channels Context: During the coronavirus pandemic, leaders and managers have had to deal with enormous amounts of new information, disruptions to normal operations, frequent policy changes, political pressure, and uncertainty. This required unprecedented effort to be devoted to communication in order to allay concerns and explain new policies or actions, or why previous decisions or actions were being reversed. It was learned that providing and eliciting information enables problem-solving, contributes to staff well-being and to effective patien care under challenging circumstances. Aim: To improve understanding and trust. New information, policy and decisions are sent through frequent, multi-channel, communication, not only to stratified professional groups but across multi-functional units. Provide confidence that political pressure is being buffered by leadership. Description: Multiple channels may be needed. These include virtual, technology-mediated communication using WhatsApp, video clips, email, and face to face engagements in the wards and clinics or administrative workplaces. Online channels cannot always reach all staff but all staff, especially clinical/hospital staff benefit from direct, in person communication where this is possible. ihi.org 21 Title of the Document Happens Here We now know that staff can be protected through congregating only in adequately ventilated spaces, wearing good quality well fitted masks, and vaccination, which means most staff can return to face-to-face interactions with these precautions in place. It is useful to set up WhatsApp groups for different communities. The group admin/moderator can periodically remind everyone about the rules of constructive engagement and acceptable behaviour. Managers need not be members in all groups; members may feel inhibited by management membership. Rules should be set for behaviour, engagement, and distribution of content outside the group in these communities. The group can also set expectations for when messages are sent and reasonable response times. Some groups may be only “push” – where only administrators can send messages, usually for pure information purposes but in this case should have alternatives ways for recipients to get more and have questions answered. Communicating often, with relevant information, is the key aspect in times of crisis, and finding ways of respectful interaction with all staff. Summarise and repeat key information and guidance often. Provide regular summaries of key informational items. The communication channels can regularly broadcast changes in policy, SOPs, successes. A WhatsApp platform can be used for real-time mentorship, coaching, to encourage peer to peer learning and also to promote healthy competition among teams. #StaffCare leaders liked the idea of reserving one day a week for important new announcements such as key policy changes. Where resources are available, it is helpful to create templates or dashboards with standard information (e.g., hospital occupancy, case numbers, HCW cases, etc.) that can be frequently updated and shared are very useful. Physical (“white”) boards are an inexpensive alternative. In groups, monitor changing patterns of participation and attendance. Expect a natural waxing and waning – slowing down or stopping is not necessarily a sign of failure. Provide daily situation reports (“SitReps”) for teams (online or in-person). 3. Conduct Regular Team Huddles Contributors: Stephan Fourie, Paarl Hospital. Aghmat Mahomed, Groote Schuur Hospital Context: Huddles are an important addition or enhancement to leadership practices that have gained momentum during the Covid-19 pandemic. It is believed that the majority of organisations in the WC Health Department system are using huddles, though they may not conform to any official definition. Huddles provide a space where teams engage either in an informal, semi structured, or more structured way depending on the system need and the aims. Aim: In the #StaffCare context, the aim of huddles is to provide a rhythm of brief, structured staff engagements that are not only essential contributors to efficient and effective operations but allow everyone to feel connected and listened to in an environment of psychological safety. ihi.org 22 Title of the Document Happens Here Description: IHI defines a huddle as “a short, stand-up meeting — 10 minutes or less — that is typically used once at the start of each workday in a clinical setting. In inpatient units, the huddle takes place at the start of each major shift.” Figure 8: Principles for huddles (Paarl Hospital, WC) (1) Huddles are not meetings The distinction between huddles and other types of engagements is important. Huddles differ from ordinary business meetings: they are planned, short (usually no more than 10-15 minutes), and are regularly scheduled - often at shift change or daily, or less frequently (e.g. 3x per week, weekly, monthly, etc). Huddles provide an opportunity to hear the concerns of staff in an atmosphere of psychological safety and can be one place where positive stories are shared. When held face to face, huddles are generally, but not always, stand-up. This helps create the expectation of being short and focused. (2) What is the content of a huddle? Huddles work best when they are structured and use a standard template or at least agreed principles. The content of shift change huddles often includes summarising preceding activity (e.g. previous 24 hours, or night); helping to establish and communicate plans for the next shift/day/week/month; providing new information or updates on any urgent or priority issues. Consider starting (or ending) each huddle with a frontline worker story or observation. Huddles can also begin with a brief moment of reflection, mindfulness, or prayer. In doing so, think about how to accommodate widely different practices, preferences, beliefs (e.g. religion). (3) Who is in a huddle? Huddles are purposefully lead. Leadership can rotate; this is necessary when huddles are scheduled daily or at shift change. Rotation of leadership helps to grow leadership capability. Huddles can bring together staff from a single discipline (e.g. daily nursing huddle) or can be multidisciplinary and may span a functional team (clinical and managerial). In a multidisciplinary huddle, try to give voice to as many people from as many disciplines as possible over the course of a month (4) Huddles and staff well-being Huddles provide the opportunity to check in on team general wellbeing: asking about “what matters” and responding to the need “hear me” (Table #). ihi.org 23 Title of the Document Happens Here During huddles is uplifting to offer commendations and congratulations and celebrate individual and group achievements, big or small. During huddles, input from staff can be solicited in a focused way, generally without extensive back and forth, rather providing a path outside of the huddle to fuller investigation or problem solving. Make the huddle a psychological safe space (Table ) with diminished/flattened hierarchy. Think about how all participants can be named and addressed respectfully, setting the right tone. (5) A system of huddles Huddles can start small and be standalone. They can also be connected the system (“escalating huddles”), so that important new or established issues can quickly reach attention at the appropriate level of the organisation. Progressive health care organisations are establishing systems of huddles across units, multidisciplinary teams, and communities of practice, connecting frontline teams to senior leadership every day to bring issues quickly to attention with rapid, acknowledgment, feedback and decision-making. (6) Tools, measurement and evaluation Whiteboards are a common accompaniment of huddles in clinical workspaces (Figure #). A huddle whiteboard may contain aim statements and principles or mission statement, data in the form of run charts, news items, and policy excerpts. Measurement can help leaders to understand how and whether their huddles are working. Strict attendance rosters are generally not needed but recording levels of attendance and of the presence of participants all disciplines is useful; dropping attendance figures can prompt reassessment; attendance that is sustained can help affirm the value. In common with other staff engagements, the need and value of any particular huddle should be re-evaluated periodically; measurement is useful to help determine the ongoing need. ihi.org 24 TABLE 2: Tips on how to listen to Staff concerns and ideas for change (From www.IHI.org) Hear Me: Listen and act on lived experience to understand and address concerns to the extent organisations and leaders are able Do Don’t Steps to Try Sustain Joy in Work Conduct frequent, brief Assume you know Ask: “What concerns do you have Continue well-being “well-being huddles” (at since concerns may for patients, yourself, or the team?” huddles to learn about the beginning and end vary by individual current pressing issues for of work shifts) to learn Ensure you understand by staff and focus on what about current pressing Ignore the strengths confirming: “Here’s what I hear you matters most to care teams issues and bright spots saying — do I have that right?” Ask: “What do we still need to learn?” Try different small tests to Listen, do not interrupt Underestimate the identify the huddle time, learning required Ask: “What can we do together agenda, and facilitation Learn what is going (and time it takes) to that would help right now?” structure that works for well, not just problems care for patients with each group COVID-19 in addition Acknowledge the to other patients complex emotions of delivering care in the face of uncertainty Recognize that Promise to fix an Ask: “Are there steps we can Empathize with staff frustration and anger issue when you may take right now, as a team?” when they encounter are part of the not be able change and invite them upheaval, not a Ask: “How can we do this together?” to co-design it personal attack Make decisions that Ask: “What can we stop doing? affect staff without What makes no sense to Partner with staff in their contribution continue?” decisions that affect them Recognize that Judge or deny Acknowledge and support: “No one Create a peer support individuals respond has ever gone through what we’re and coaching network differently to stress, and dealing with now. Together as a fear may be expressed team we will take steps that make as concerns (e.g., with sense for us and we’ll learn from regard to PPE: “…not others.” enough, wrong sort, too flimsy…”) Listen to the concerns and the emotion — “It sounds like you are very worried right now” — then address the facts Promote Be threatened by Affirm: “Never worry alone — if Develop conversation psychological safety staff speaking up you have a question, so do skills that create a others.” psychologically safe space for team members to share Ask: “What are you most what matters and what’s worried about right now?” getting in the way of more good days Invite staff to share Assume people Ask: “What good thing Conduct both one-on-one positive stories with one have a way to happened today?” and team conversations another process their unique about “What Matters to experiences You” ihi.org 25 Title of the Document Happens Here Figure 9: A Huddle Board at Paarl Hospital, WC Figure 10: Huddle board at Groote Schuur Hospital ihi.org 26 Title of the Document Happens Here Table 3: A daily measurement template used in huddles at Groote Schuur Hospital, WC. 4. Conduct Meaningful Business Meetings Context: During the #StaffCare initiative leaders frequently commented on the burden of frequent lengthy meetings that did not add value. Excessive meetings and meeting time encroached on other activities and unacceptably extended the working day. During the Covid-19 pandemic the need to rapidly absorb new information and respond to changing circumstances meant an expanded working day into nights and weekends. Inefficient meetings reduce management capability to make effective, prompt decisions and generated frustration impacting on physical and mental wellbeing of participants. Aim: For all business meetings to be run in ways that foster purpose, meaning and value. Nobody should attend a business meeting in which they do not have an active role. Description: Effective meetings usually have an agenda; most regular meetings can conform to a simple one that repeats. Importantly, there is a need for reflective engagements as well as for engagements that invite strategic thinking. These engagements benefit from unstructured open agendas with good facilitators. Participants should come on time and the meeting should end on time (or before, if the work is done). Make sure there are breaks between meetings. It is worth considering scheduling all 30 minute meetings for 25 minutes or 1 hour meetings for 55 minutes to allow for recovery time, preparation for the next meeting or other activity, and arrival on time. Schedule more meetings to be of shorter duration, as content tends to fill the available time. ihi.org 27 Title of the Document Happens Here During virtual meetings, consider generating the record of discussion in real-time, visible to participants; this allows input, helps achieve consensus, saves time by avoiding the minute taker having to commit additional time to do so afterward. Periodically review whether a meeting is required. Can it be reduced in frequency or amalgamated with another? Consider who needs to attend; encourage individuals to leave and pursue more urgent or productive activities if their active participation is not needed, and they can receive information later on in a different way. Following a meeting, reflect on its need and effectiveness. For virtual meetings, which greatly expanded during the coronavirus pandemic, it is just as important as with face-to-face engagements to start on time. Keeping cameras on as much as possible, if bandwidth is available; or at least at the beginning and end of a meeting helps to establish and maintain human connection. Use the chat function to share links, small pieces of information, files, etc. The person(s) running the meeting should scan the chat for inputs the conversation; if it’s not possible for that person to do so, someone else should be assigned to monitor, respond, input to the group. The chat can substitute for some aspects of face-to-face conversation including the body language of participants, nods of assent or disagreement, degrees of approval. Use the ‘hand raised’ function to conduct an orderly meeting in which all who desire can participate. Make sure that every person attending has the opportunity to contribute at least once. According to the Harvard Business Review2, there are four broad reasons to hold meetings: to influence others, to make decisions, to solve problems, or to strengthen relationships. These are all active processes, so passive participation in meetings doesn't really work. 5. Establish Trusting Relationships with Organised Labour Context/problem/opportunity: Conflict between management and organized labour in health care workplaces has the potential to severely disrupt operations of the health system and create stress and hardship for all staff and patients. Conversely, harmonious relations create stability and can enjoin labour union leaders to be valued partners in supporting and protecting the health care workforce. During the coronavirus pandemic Organized Labour in some locations downed tools and took industrial action because of concerns for the safety of workers. These concerns, primarily around PPE and high rates of staff infection later reduced as these safety concerns were met. 2 https://hbr.org/2020/03/how-to-get-people-to-actually-participate-in-virtual-meetings ihi.org 28 Title of the Document Happens Here Some health systems handled this better and #StaffCare exposed and shared lessons from these experiences which are helpful going forward. Organized Labour Unions are provided for in the Constitution and Labour laws of South Africa. The tripartite alliance of the ruling party with the COSATU labour organisations has often allowed an imbalance in power, complicating the management of services, leading to an unstable shopfloor. There is little that health care organisations to alter these dynamics but it is possible, over time, and with considerable investment in trusting relationships and shared values, to design and implement a compact between labour and management. Aims: Labour & management can jointly define the nature and responsibility of a partnership arrangement for collective #staffcare. The aim is to create peace in the workplace based on mutual trust; labour and management have roles defined in the maintenance of trusting good relations which are created through frequent clear communication, invited participation and shared responsibility for problem solving & communication. Description: • Organised Labour and labour-management structures exist at central and local levels. Established structures (e.g. IMLC – Institutional Management and Labour Committee) may be in place but are sometimes dysfunctional. Health local relationships can nevertheless overcome dysfunctional central relationships. • It is expected that organized labour is invited to be at the table when matters that might affect their members are addressed. • Share information with Labour representatives. • Upgrade knowledge and skills of Labour in technical areas (e.g., new policies and PPE) that may impact on staff wellbeing, in relevant legislation and healthier modes of interaction (e.g. consultation). • Use the conceptual framework (see Figure 10 below) of management-labour relations to set aims and define responsibilities. • Start small and build personal relationships through regular, open and transparent communication and mutual respect. • Develop a compact between labour and management at both central and local levels. • Hold regular meetings e.g., about staff infections, PPE stock availability, policies, response strategies. • Engage Organised Labour in co-design of improvement (e.g., new operational policies around Labour issues. • Provide regular information to shop stewards to share with members. How to measure this action: • Number of strikes, days lost to industrial action • Levels of activity of formal structures • Measures of staff wellbeing including #injuries and other harm • Surveys of labour and management leaders ihi.org 29 Title of the Document Happens Here Figure 11: The concept of a compact between organised labour & health system leaders was formulated after meetings with senior management and union representatives in W Cape. Prevent and Manage Harm to HCWs 6. Prevent infection and other forms of harm Context: From the beginning of the coronavirus pandemic, doctors and nurses have been at risk working in Covid wards and ICUs. Early on, this risk was thought to be highest during so-called aerosol- generating procedures e.g. intubation, but mainly transmitted by droplets at short range (1-2m) and via fomites. Covid-19 is now recognised to be an airborne disease, transmitted primarily through the air, at short and long range, by persons with and without symptoms of the disease. HCWs faced significant risk through exposure to patients with confirmed or uncertain Covid status in other clinical areas such as postoperative recovery or outpatient clinics, requiring precautions (e.g. mask wearing by patients and staff) to be taken throughout the facility. We learned that infection could also be acquired from colleagues and co-workers in confined indoor areas such as cafeterias and offices, and that as the pandemic grew, the risks to staff living in crowded communities and during the commute to and from work were as high or higher than the risks of infection that they faced at work. Because of particle emission rates, the risk is much higher where infected persons are speaking or shouting than with quiet breathing. During the pandemic other infectious and non-infectious risks to staff have not disappeared e.g. nosocomial TB (also an airborne disease) and other pathogens, workplaces injuries, assault by patients, etc. All of these require to be considered in efforts to protect staff. With most health care workers now vaccinated, the dominant issue has become how to relieve HCWs of the accumulated and continuing severe emotional strain incurred at work, in society and at home. Aim: ihi.org 30 Title of the Document Happens Here Multiple aims may be considered: to prevent infection and other forms of harm, including Covid- 19 acquired from patients, and from staff; to create capability, and a sense of accountability, for protecting each other. Good “protective behaviour” should not only happen when observed; to ensure reliable and equitable allocation of PPE and reduced variation in staff PPE policies.; to strengthen team trust and make staff feeling protected and cared for. Description: Vaccination reduces but does not fully prevent the acquisition or transmission of Covid-19. The same applies to staff with previously infected with SARS-CoV-2. To protect staff, even those vaccinated, precautions and mitigations are needed in both clinical and non-clinical areas of all health care facilities. Non-clinical staff have had equally high or higher rates of infection than staff working in Covid ICU or other Covid wards. Precautions and mitigations therefore apply in these areas to reduce the transmission of airborne disease – not only Covid, but TB and other respiratory illness. Improving ventilation throughout the facility should be a priority. Ventilation is a key factor in limiting the spread of airborne disease; engineers and building managers should assess ventilation in all parts of the facility where staff and patients are accommodated. Ventilation may be improved by opening windows, to create a flow of fresh air, however this is not always possible because of the need for thermal comfort. Wear good quality masks properly at all times, covering nose and mouth. When removed – e.g. for eating, observe physical distancing in well ventilated spaces (outdoors is best if possible). Learn best practice from colleagues who routinely care for patients with severe airborne disease e.g. those caring for patients with MDR- and XDR-TB. Provide staff with safe transport services. WC deployed Red Dot transport, which prioritized HCWs and patients, in a COVID safe environment. This approach addressed the reality that commuter taxis are often densely packed with passengers. On longer journeys with few stops, they are poorly ventilated unless windows are opened throughout. Re-design or re-arrange additional communal spaces (e.g. tea rooms, locker rooms) where meals may be eaten safely and in pleasant surroundings. Re-design flow in all care and non-care areas (green, red, PUI) and create “forced” PPE donning/doffing pathways. Standardize PPE equipment across all health worker cadres. Equitable distribution of good quality PPE sends a very strong signal that all health care workers are valued. Place visual reminders in the facility about PPE and effective Personal Protective Behaviours (PPB). Share strategies and mental models for individuals and teams e.g. “Live in the black box” i.e. create a safe zone around you at work at all times, to keep all person to person interaction low risk. Table 4: Physical and Psychological Safety . Adapted from IHI Conversation Guide (www.ihi.org) Protect Me: Reduce the risk of acquiring COVID-19 and/or being a transmitter to family ihi.org 31 Title of the Document Happens Here Do Don’t Steps to Try Sustain Joy in Work Be fact-based Make things up just Reassure and inform: Establish and to have an answer support a physically “We have X days’ supply of PPEs safe work on hand.” environment “Here’s what we’ve learned from other health systems (or states). Conduct Which of hazard these ideas do you think we could assessments test?” “Testing is available for staff — Create simple, trusted here’s how you get it.” workplace injury and “Steps to protect your family before violence reporting you go home are…” systems Focus on what we Assume everything Ask: “What decisions can we make Engage staff and can control is chaos together about how we manage the patients/families in volume of patients we expect (or co- designing safe Use quality have) using the PPE available?” systems improvement methods and conduct small Ask: “What can we test this morning?” tests of change Offer realistic hope Provide false Inform: “We have PPE shipments Share all data assurances: “We’ll arriving tomorrow. Local companies transparently be are making PPE shields for us that through this in 2 weeks” will be ready in X days.” 7. Take care of colleagues who become infected or experience other workplace harm or injury Context: By August 2021, more than a third of HCWs in the Western Cape had been infected with Covid- 19. It is hard to know what proportion of infection were acquired in the workplace. In WC, HCW infections were carefully tracked; they rose and fell exactly in tandem with the changes in infection rates in the general population. HCWs benefit from knowing that the organisation, co-workers and their team-mates care about preventing harm in the workplace. When HCWs become sick or are injured, efforts to reach out and assess areas of need for individuals and their families are valued, including those that the organisation can itself address. This was critically important in the early stage of the pandemic, and of continued importance now as HCWs still face risks to their physical health – e.g. nosocomial TB, workplace injury, assault by patients. A unique aspect of the pandemic has been that the exposure of co-workers has had to be considered when any person is diagnosed, and therefore to establish effective, uniform and consistent ways to measure and reduce that risk to others (tracking and tracing). Figure 12: Healthcare worker infections dashboard ihi.org 32 Title of the Document Happens Here Figure 12 shows that by August 2021 more than a third of WC health care workers had been infected with SARS-CoV-2 over the three waves Aim: To implement effective and consistent approaches to contact tracing and post-exposure policy. Staff need a connection with a trusted person in the community or someone from Occupational Health. Have strategies to boost staffing numbers in a crisis. Description: • Where applicable, identify a community carer (e.g., GP, occupational health nurse) for each infected staff member. • Call staff who are sick daily to check on them and their family. • Keep a register of positive cases, contacts and risk. • Review staff duty allocations daily - shift staff roles, use agency staff, use students or worker categories to cover staffing gaps. ihi.org 33 Title of the Document Happens Here Figure 13: Trends in cases over time since 1 June 2021 Table 5: Physical and Psychological Safety (Adapted from IHI Conversation Guide) Care for Me: Provide holistic support for team members and their families, if isolation is required (or othersources of distress occur) Do Don’t Steps to Try Sustain Joy in Work Identify what support looks Ignore the personal Ask: “What would support look Assess effective like for staff and their and family toll on staff like for you today?” support systems for all families Address the basics: Food, Mobilize efforts to obtain medicine, safe housing, PPE, support: use volunteers, child care social workers, community members Recognize that mental Ignore that staff may Offer assistance: “Our mental Provide accommodations illness may increase during have mental health health is vital for all of us and our for mental health needs times of intense stress needs patients. Let me or your provider know if you need help.” Create a peer support and coaching network Find ways for staff to Assume that stress will Provide support: Build on learnings about support colleagues who not affect everyone’s effective support in “Here are resources to support are (or have family well- being times of great stress one another.” members who are) sick or have died from COVID-19 “Let’s take a minute to think of Joseph’s family.” Ensure staff know Assume that staff Inform: “HR partners will provide Develop more robust HR about resources if know how to navigate the information you need and systems based on they are furloughed HR or government make sure you get all your learnings agencies on their own questions answered.” ihi.org 34 Title of the Document Happens Here 8. Ensure staff are knowledgeable and prepared Aim: To improve understanding of infection transmission and protections. Experience suggests constant, repeated communication is required to keep staff informed and feeling that they are engaged and current in their knowledge, enabling highly reliable protective processes to become the norm. Description: § Use apps that provide teaching videos on PPE and procedures § Use daily reminders in huddles to encourage and support behaviours that protect and reduce risk of transmission § Place visible signage/posters to remind staff about preventive and protective measures Table 6: Autonomy and Control Prepare Me: Provide training and support for high-quality care in different settings Do Don’t Steps to Try Sustain Joy in Work Be honest Assume you know Acknowledge: Provide training based what each person on lessons learned and needs to be competent “I know this is scary to change in relationship- in new roles or work roles this quickly.” centered communication skills “We have training plans and want to hear how it’s going for you every day.” Be clear Provide information Ask: “Here are the steps we have Share what you know that staff do not need planned to help you give quality and what you don’t or will not use ICU care. What else do you think know you’ll need today?” Share good and news Encourage rapid tests Blame when Ask: “These are the three tests we Highlight learning of change and failure happens have going right now — any ideas gained to decrease fear learning on them?” of failure Communicate via Rely on email Inform: “We have huddles two Harvest lessons learned real- time methods: times each day; regular COVID-19 about effective instant messaging, Assume people have updates are available online.” communication to a range huddles, video all the information they of staff conference need if they are not Ask: “What questions do you have?” asking questions Ensure that staff can easily communicate to leadership Develop “safety nets” Expect people in Offer assistance: Harvest lessons learned for staff new roles to function about effective staffing, new quickly with limited “This shift Hendrina is your workflows, and successful support support person. You can ask her tests; see change package anything.” for specific examples “Team members are here to help one another. Never worry alone.” ihi.org 35 Title of the Document Happens Here B. Preserve mental and physical health of HCWs Main messages: The emotional health of health care workers has been a major concern for some time, heightened now by the severe challenges of the pandemic and leaders need to prioritise this problem. It has required them to identify the major contributors to staff stress and anxiety, and the factors that could reduce this. Leaders need to consider systemic solutions alongside the provision of individually focused mental health and other professional services. The actions of mid-level leaders can be a major contributor to alleviation of stress. They may do this through leadership practices and behaviours that change workplace culture, empowering individuals and teams to take action to improve the clinical and administrative processes of health care, and take better care of each other, thereby increasing joy in work. 9. Support the Emotional well-being of staff Contributor: Misha Naik, Occupational Therapist, Co-Lead GSH Wellness Unit, Groote Schuur Hospital Context: During the pandemic and post-pandemic, it will be wise to frequently evaluate and address the traumatic and post-traumatic state of staff and try to deeply understand causes of anxiety and act on them, provide additional resources for emotional care, and evaluate for physical and emotional exhaustion. Leaders may use multiple formal and informal inputs to assess the state of well-being of staff, including Leadership Rounds, huddles, debriefing sessions, surveys (e.g. emotional pulse check survey) and measures of staff absenteeism. Leaders should be aware of professional services that are available for their teams and how they may be accessed. Novel interventions such as buddy systems or other peer-to-peer support may be tried, with support. Aim: To take action to understand and address the systemic sources of emotional suffering among staff. Description: Many leadership actions have been described as being useful in supporting the emotional well- being of staff in a variety of settings. Proactive leadership examples included: • Creating bronze command meetings to facilitate regular communication with all departments in the hospital. • Changing the methods of communication, and through various platforms- be it virtual or in person ihi.org 36 Title of the Document Happens Here • Decentralizing decision making and allowing each department to problem solve ways that they could accommodate the change in working schedules, to minimize staff infection. Figure 13: Debriefing Grieving and debriefing sessions after trauma have been important for healing. These were put in place after the second, severe pandemic peak, and may be highly valued as the third wave ends. Debriefing is not counselling. It is a structured voluntary discussion aimed at putting an abnormal event into perspective. It offers workers clarity about the critical incident they have experienced and assists them to establish a process for recovery3. In the WC debriefings take four different forms – formal offerings provided by professionals from a contracted provider (Metropolitan), individual counseling, informal sessions in leadership spaces, and also a planned program of collective grieving and healing sessions. Celebration and acknowledgment (“HONOUR ME”) have been very important ways to build morale, raise spirits and provide expression of a genuine caring culture. Very positive reported benefits come from small gestures of acknowledgment and caring, such as gifts of hand cream, to sharing of food, to joyful events such as Jerusalema dances, musical events and Christmas parties. Figure 14: Celebration activities from George Hospital (Courtesy Dr Mike Vonk) • Be visible to 3 https://www.betterhealth.vic.gov.au/health/healthyliving/workplace-safety-coping-with-a-critical- incident#debriefing ihi.org 37 Title of the Document Happens Here front line teams and support staff daily. When leaders and managers are seen in clinics and wards, even for brief periods, this can have a very positive effect, and create opportunities for understanding and addressing their concerns (see Huddles; see Leadership Rounds). • Voice your concern and care. During the darkest hours of the pandemic, leaders could say, for example, “I can see you’re afraid and unsettled”, “you’re not alone, I’m here with you, I’ll be here again tomorrow”, “let’s talk, what do you need?” • Provide a designated Occupational Health Nurse where that is possible. Where unavailable, support by peers can be an acceptable and scalable substitute. Staff would need education and training in how to provide such support, knowing their limitations and knowing when it is essential to gain access to professional counseling or other forms of professional support. Buddy pairings and peer groups can be successful. • Celebrate staff upon their return to work after absence due to illness or trauma. They can be invited to share their stories with staff and to debrief one-on-one or in groups but should never be required or pressured to do so. Celebrate patient recoveries as these boost the morale of the wider team. • Many types of communal activities boost staff morale including any opportunity for light physical activity (e.g., walks, yoga, Jerusalema) • Screening staff periodically for signs of PTSD and burnout can be undertaken by HR and OHS. Digital tools may be available to do this at scale, but this should be done in collaboration with professional mental and occupational health services. • Criteria for PPE and other protections may need to incorporate the concerns of staff. These may not always be fully supported by evidence. For example, during the peak of the first Covid-19 wave, staff requested additional gowns etc for which there was no evidence of benefit, but permitting this seemed to offer emotional comfort and reduced anxiety certain staff needed. • Equality of PPE – in other words that senior clinical staff were seen to be using exactly the same PPE as other staff members – served to reassure and establish that the safety of all staff was equally valued. • Create opportunities for staff to take time off for rest and only cancel/reduce planned leave as a last resort. Providing extra leave days when staffing pressures are reduced are among the most highly appreciated interventions. • Foster supportive and open communication around Covid-19 fatigue, burnout and other causes of stress and burnout. Many HCWs obtain their support outside the workplace, via private practitioners. ihi.org 38 Title of the Document Happens Here Table 7: Themes from on-site counselling at Groote Schuur Hospital based on Shanafelt’s 5 themes (Source: Misha Naik, GSH Wellness Team) Figure 15: The “emotional heartbeat” or “emotional pulse check” survey which was crafted by #StaffCare, based on the Shanafelt themes that identify concerns of health care workers during the Covid-19 pandemic. ihi.org 39 Title of the Document Happens Here Figure 16: George Hospital used results from the emotional pulse check survey to connect the status of their staff to the Sensemaking Framework and decide on possible improvement and action. Figure 17: Marble project - New Somerset Hospital – theatre staff place a marble in the jar at the end of the day, indicating either a good day or one not so good, and are encouraged to describe the reasons ihi.org 40